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Journal name: Archives of psychiatric nursingNIHMSID: NIHMS455911

Manuscript Title: Feasibility, acceptability, and effects of gentle Hatha yoga for women with major depression: Findings from a randomized controlled mixed-methods study

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Title: Feasibility, acceptability, and effects of gentle Hathayoga for women with major depression: Findings from arandomized controlled mixed-methods study

Authors: Patricia Anne Kinser, Cheryl Bourguignon, DianeWhaley, Emily Hauenstein, Ann Gill Taylor

PII: S0883-9417(13)00033-2DOI: http://dx.doi.org/10.1016/j.apnu.2013.01.003Reference: YAPNU/50548

Published in: Archives of Psychiatric Nursing

Received date: 14 August 2012Revised date: 25 January 2013Accepted date: 28 January 2013

Cite this article as: Kinser PA, Bourguignon C, Whaley D, Hauenstein E, Taylor AG,Feasibility, acceptability, and effects of gentle Hatha yoga for women with majordepression: Findings from a randomized controlled mixed-methods study, Archivesof Psychiatric Nursing, http://dx.doi.org/10.1016/j.apnu.2013.01.003

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Feasibility, acceptability, and effects of gentle Hatha yoga for women with major depression:

Findings from a randomized controlled mixed-methods study

Patricia Anne Kinser,1* PhD, WHNP, RN Cheryl Bourguignon,2 PhD, RN

Diane Whaley,3 PhD Emily Hauenstein,2 PhD, RN, LCP Ann Gill Taylor,2 EdD, RN, FAAN

1Virginia Commonwealth University, School of Nursing, Richmond VA 2University of Virginia, School of Nursing, Charlottesville, VA

3 University of Virginia, Curry School of Education, Charlottesville VA

* Corresponding Author: Patricia Anne Kinser, PhD, WHNP, RN Email: kinserpa@vcu.edu Telephone: 804-828-9140 Virginia Commonwealth University School of Nursing 1100 East Leigh Street, PO Box 980567 Richmond, VA 23298

Acknowledgments This publication was made possible by grant number 5-T32-AT000052 from the National Center for Complementary and Alternative Medicine (NCCAM). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of NCCAM. The authors thank all of the members of the study team, particularly Mindy Loiselle and Robert Goldschmidt (certified yoga teachers), Debbie Seegers, Karyn Schultz, and Kalay Naidoo (registered nurses), and Joan Plotkin-Han (on-call psychiatrist). We thank Amy Weintraub for the use of her LifeForce Yoga DVD.

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Yoga for Women with Depression 1

Abstract

Major depressive disorder (MDD) is a common, debilitating chronic condition in the United

States and worldwide. Particularly in women, depressive symptoms are often accompanied by

high levels of stress and ruminations, or repetitive self-critical negative thinking. There is a

research and clinical imperative to evaluate complementary therapies that are acceptable and

feasible for women with depression and that target specific aspects of depression in women, such

as ruminations. To begin to address this need, we conducted a randomized, controlled, mixed-

methods community-based study comparing an 8-week yoga intervention with an attention-

control activity in 27 women with MDD. After controlling for baseline stress, there was a

decrease in depression over time in both the yoga group and the attention-control group, with the

yoga group having a unique trend in decreased ruminations. Participants in the yoga group

reported experiencing increased connectedness and gaining a coping strategy through yoga. The

findings provide support for future large scale research to explore the effects of yoga for

depressed women and the unique role of yoga in decreasing rumination.

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Yoga for Women with Depression 2

Introduction

One of the most common and debilitating health conditions in the United States and

worldwide is major depression, considered in this paper to include major depressive disorder

(MDD) and dysthymia (Branchi & Schmidt, 2011; Kessler et al., 2003). Clinically, the condition

presents as a persistently depressed mood with anhedonia, feelings of worthlessness, impaired

cognitive abilities, altered sleep and appetite patterns, and suicidal ideations (American

Psychiatric Association (APA), 2000). Epidemiological studies have demonstrated that women

are disproportionately affected by depression, such that women have approximately double the

prevalence rate of depression compared to men (Kessler et al., 2003). The interplay of biological

and psychosocial vulnerabilities, stress, and individual personality and coping behaviors may be

responsible for this increased prevalence of depression in women (Kinser, Goehler, & Taylor,

2012).

Depression is a complex disorder that can be difficult to treat successfully. Many women

with depression express frustration about the usual care, citing reasons such as inadequate

symptom management, unacceptable side effects, and inadequate methods for coping (Kessler et

al., 2003; Lafrance & Stoppard, 2006; S. Nolen-Hoeksema & Hilt, 2009). The efficacy of the

usual care for depression (pharmaceutical management and cognitive therapy) is poorer than

originally thought; recent close evaluation of large-scale studies on these usual care methods has

revealed large participant dropout rates and low remission rates as well as generalized reporting

bias (Mathew & Charney, 2009; Pigott, Leventhal, Alter, & Boren, 2010; Turner, Matthews,

Linardatos, Tell, & Rosenthal, 2008). More research is called for regarding innovative

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Yoga for Women with Depression 3 psychosocial treatments, particularly in typically under-studied populations such as women with

severe depression (National Institute of Mental Health, 2005).

Although depression is characterized by a depressed mood, many women experience a

variety of psychological, cognitive, and physical symptoms beyond the depressed mood (APA,

2000). For example, up to half of all women with a diagnosis of depression may experience

“anxious depression,” typified by excessive ruminations (Halbreich & Kahn, 2007; Marcus et al.,

2008). Rumination is a complex concept, typically defined as repetitive negative thinking about

one’s depression and life situations (Smith & Alloy, 2009). Individual differences in coping

patterns and ruminations play a role in the cycle of stress and depression (Hauenstein, 1996;

Nolen-Hoeksema, 2006). Rumination is generally considered to be an emotion-focused coping

style that is often ineffective or maladaptive because it can perpetuate stress and depressive

symptoms (Lyubomirsky & Tkach, 2004; Weinstein, Brown, & Ryan, 2009). A low sense of

mastery seems to contribute to brooding, a factor of rumination, when one repeatedly

contemplates what’s wrong in one’s life and why it is not better (Treynor, Gonzalez, & Nolen-

Hoeksema, 2003). As such, there is a research and clinical imperative to evaluate complementary

therapies that are acceptable and feasible for women with depression and that target specific

aspects of depression in women, such as ruminations. Yoga is a commonly practiced

multifaceted mind-body modality that warrants attention for its potential use for depression

(Barnes, Bloom, & Nahin, 2009; Birdee et al., 2008; Uebelacker et al., 2010).

Yoga for Depression

Findings from numerous studies suggest that various yoga interventions may help

decrease psychological and physical symptoms of depression and stress in a variety of clinical

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Yoga for Women with Depression 4 and non-clinical populations (see multiple review articles: Kirkwood, Rampes, Tuffrey,

Richardson, & Pilkington, 2005; Pilkington, Kirkwood, Rampes, & Richardson, 2005;

Uebelacker et al., 2010). Only a small number of studies have rigorously tested the use of yoga

for individuals with diagnostic levels of depression (i.e., MDD or dysthymia). Results of the few

randomized controlled trials (RCTs) of yoga for MDD or dysthymia suggest that yoga may

improve the mood or prevent recurrence of major depressive episodes (Broota & Dhir, 1990;

Butler et al., 2008; Janakiramaiah et al., 2000; Sharma, Das, Mondal, Goswampi, & Gandhi,

2005). A recently conducted open trial of yoga for MDD found that yoga may be feasible for this

population, yet the study did not evaluate adherence to the intervention or ruminations

(Uebelacker, Tremont et al., 2010). Considering that brooding ruminations are associated with

increased depression symptoms and suicidality in women, it is recommended that studies include

ruminations as an outcome of intervention studies for depression (Lopez, Driscoll, & Kistner,

2009). Unfortunately, the limitations of research studies on yoga for depression abound, ranging

from methodological issues with RCTs (Broota & Dhir, 1990; Butler et al., 2008; Janakiramaiah

et al., 2000; Sharma et al., 2005) to the use of healthy participants or those with only a self-report

of depressive symptoms (i.e., no confirmation of diagnosis of depression), unclear

inclusion/exclusion criteria, and intervention lengths shorter than typically used in

pharmaceutical treatment studies for depression (i.e., less than 8 weeks) (Pilkington et al., 2005;

Uebelacker et al., 2010). Furthermore, most studies do not focus on the particular symptoms

related to depression in women, such as repetitive negative thinking (ruminations) (Conway,

Csank, Holm, & Blake, 2000; Morrison & O'Connor, 2008; S. Nolen-Hoeksema, Wisco, &

Lyubomirsky, 2008; Smith & Alloy, 2009).

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Yoga for Women with Depression 5

Despite the limitations of previous studies, the preliminary evidence supports a need for a

closer evaluation of the feasibility, acceptability, and mechanisms of effects of yoga for

individuals with major depression. The most generally accessible form of yoga in the United

States, Hatha yoga (simply called “yoga” henceforward) is a mind-body modality that combines

physical practices, breathing practices, and relaxation/ meditative practices intended to enhance

overall health and well-being (Desikachar, Bragdon, & Bossart, 2005; NCCAM, 2010;

Uebelacker et al., 2010). Yoga may be an appropriate coping intervention for depression, as it

can be self-administered, can be specifically adapted to one’s mood, and is safe for yoga-naïve

individuals (NCCAM, 2010; Weintraub, 2004). The symptoms of depression often affect daily

functioning and prevent women from participating in social, physical, or other self-care

activities. It is these very symptoms that can potentially be reduced by a mind-body intervention

such as yoga, if women with depression will accept and participate in yoga sessions. As such, the

primary aim of the randomized, controlled, pilot study was to evaluate the feasibility and

acceptability of an 8-week yoga intervention specifically designed for women with depression.

Our secondary aim was to evaluate the effects of yoga over time as compared to an attention-

control group. The study is based upon a biobehavioral paradigm focusing on the cyclic interplay

of stress, stress appraisal/responses, and allostatic overload/ depression in women (see

Hauenstein, 1996; Kinser, 2012; Nolen-Hoeksema, 2006). Our study provides important insights

for understanding and intervening with depression in women, particularly those who have

residual depressive symptoms despite treatment with the usual care.

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Yoga for Women with Depression 6

Methods

The University of Virginia Institutional Review Board (IRB) for Health Sciences

Research reviewed and approved the study protocol, recruitment plans, and guidelines for the

protection of confidentiality of participants. Written informed consent was obtained from

participants prior to their enrollment in the study; in addition to the written consent, verbal

consent also was obtained prior to audio recording the participant interviews.

Study Design

This community-based prospective, randomized, clinical intervention pilot study was

conducted in a metropolitan city on the east coast of the United States. A mixed-methods

approach with an embedded design was used to provide a comprehensive view of the feasibility,

acceptability, and efficacy of yoga for women with depression (Doyle, Brady, & Byrne, 2009;

Sandelowski, 2000). Participants continued their usual lifestyle patterns and usual depression

care.

Sampling Methods

IRB-approved materials were posted in public locations throughout the recruitment area

as well as in the offices of primary care providers, women’s health providers, and mental health

care providers. The recruitment materials advertised a free study on a complementary therapy for

women with depression. Interested individuals contacted the investigator directly. After a short

telephone screening for depressive symptoms, eligible respondents were scheduled for an in-

person visit in which consent, in-depth screening, and baseline study measures were completed.

Inclusion and exclusion criteria are outlined in Table 1. In order to be enrolled in the study,

participants were screened for major depressive disorder with a current major depressive episode

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Yoga for Women with Depression 7 or dysthymia using the MINI-International Neuropsychiatric Interview (MINI) instrument

(Sheehan et al., 1998). If a participant consented to be part of the study but then decided against

participation at any point, she was offered the opportunity to provide reasons for not continuing

by participating in a short semi-structured interview with the investigator. After the consent

process, participants were randomized into one of two groups (yoga intervention group or

attention-control group) using random numbers generated by computer.

Intervention

Yoga group: The 8-week yoga intervention involved once-weekly group classes and

daily home practice with a DVD and handouts, all of which were safe for yoga-naïve individuals.

The 75-minute group gentle Hatha yoga class was taught by experienced yoga teachers familiar

with teaching yoga-naïve students. To maintain treatment integrity, the teachers were trained by

the investigator prior to the study. All teachers used a manual during the study with options of

sequences of gentle yoga movements, breathing practices, and relaxation practices specifically

designed for depression. The yoga intervention manual was developed by the investigator using

relevant written materials on yoga for depression and through collaboration with expert yoga

teachers and borrowed from multiple gentle styles of yoga commonly found in the United States

(e.g. gentle/Hatha, Iyengar, Kripalu, LifeForce yoga) (Sparrowe & Walden, 2002; Weintraub,

2004).

The fundamental aspects of the group yoga classes are as follows: (a) creation of a safe

space and empowerment to adapt practice according to the mood, (b) intention setting with

weekly themes, (c) pranayama (breathing practices), (d) asana (physical practices), and (e) yoga

nidra (guided meditation) and savasana (relaxation). The safe space was created at the beginning

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Yoga for Women with Depression 8 of every class by the yoga teachers, who reminded participants to modify or stop any poses or

activities that were uncomfortable and/or to try something new. In addition, considering that

most depressed individuals experience the symptoms of depression to be neither predictable nor

consistent from day to day, participants in this study were encouraged to use yogic practices in a

way that best met their daily needs, which differentiates this yoga intervention from others in the

literature that do not account for individual mood differences (Halbreich & Kahn, 2007; Kinser

et al., 2012; Marcus et al., 2008; Weintraub, 2004). To help participants focus on key aspects of

the yoga intervention, every week had a theme such as self-care, finding balance, mindfulness,

and others. Pranayama, or breathing practices, taught conscious regulation of the breath, with

specific patterns designed to induce a sense of calm, well-being, stress tolerance, and mental

focus (Benson, 1975; Brown & Gerbarg, 2005a; Brown & Gerbarg, 2005b; Brown & Gerbarg,

2009; Taylor, Goehler, Galper, Innes, & Bourguignon, 2010; Uebelacker et al., 2010). Gentle

physical poses, asanas, were introduced with simple directive language and permission to adapt

as needed; the level of difficulty of the poses increased slightly over the 8-week series of classes.

Every yoga class ended with yoga nidra and savasana (guided meditation and relaxation). To

prevent distraction from intrusive thoughts, periods of silence were kept initially to a minimum

during savasana, with slowly increasing lengths of silence over the course of the sessions.

The home practices were guided by two resources for participants: (1) a DVD designed to

allow them to individually adapt their daily yoga practice according to their current mood by

picking from multiple 10-minute segments from the DVD menu (Duncan, 2007), and (2) class

handouts provided after every class with themes, quotes, pictures, and descriptions of the yoga

poses practiced that week.

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Yoga for Women with Depression 9

Attention-control group: Participants in the attention-control group engaged in a series

of health education sessions titled “Health and Wellness Program.” Involving lectures and

videos, each session was a 75-minute weekly group class for 8 weeks. Each week had a specific

theme, such as heart health, bone health, and others; handouts that included information and

additional resources on that week’s topic were provided for participants to review at home. The

classes were led by registered nurses who were trained by the investigator prior to the study. To

maintain treatment integrity, they used a manual developed by the investigator. As with the yoga

group, these classes were comprised only of study participants, and participants were made

aware of this fact during the consent process. To maintain internal validity, all efforts were made

to avoid the use of lectures, videos, or handouts that overlapped the content and essence of the

yoga intervention. To control for potential group-effect and interaction time with study staff, the

attention-control group had the same number of class meetings (8) and amount of class time (75

minutes) as the yoga group (Beal, Stuifbergen, Volker, & Becker, 2009; Lindquist, Wyman,

Talley, Findorff, & Gross, 2007; Street & Luoma, 2002).

Data Collection

For the feasibility and acceptability aim of the study, three qualitative aspects were

involved: First, a semi-structured interview was conducted with eligible women who declined

full participation in the study after the initial screening and with those who dropped out of the

study at any point; the open-ended questions were intended to elicit their reasons for not

participating. Second, semi-structured exit interviews were conducted at the completion of the

study with participants in both the yoga and attention-control groups using open-ended questions

on topics such as participants’ overall impressions about the following: the intervention itself,

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Yoga for Women with Depression 10 aspects of the intervention that were or were not beneficial, what made participation in the

intervention difficult or easy, and individuals’ plans for future use of yoga or other methods for

mood. Third, participants were invited to document their feelings about their daily yoga practice

and the type of practice used (e.g., group class, DVD, class handouts, or other) in the form of a

daily log. Participants’ use of yoga was quantified by totaling the number of minutes practiced

over 8 weeks (time in group classes plus the minutes of yoga practice per day documented on the

daily practice logs).

To evaluate the effects of group on the following outcome measures, paper and pencil

instruments were completed by participants at home:

Depression severity (timepoints- baseline, 2 weeks, 4 weeks, 6 weeks, 8 weeks):

Depression severity was evaluated using the Patient Health Questionnaire (PHQ-9), a widely

used instrument based on the diagnostic criteria for depressive disorders in the DSM-IV-TR; the

PHQ-9 includes self-report items regarding depressive symptoms over the past 2 weeks on a 4-

point Likert scale. Total scores range from 0-27, where 0-4 indicates minimal depression, 5-9

mild depression, 10-14 moderate depression, 15-19 moderately severe depression, ≥20 severe

depression. The PHQ-9 includes a question on suicidal ideation, which was used for monitoring

for adverse events (Kroenke, Spitzer, & Williams, 2001; Löwe, Kroenke, Herzog, & Gräfe,

2004; Spitzer, Kroenke, Williams, & and the Patient Health Questionnaire Primary Care Study

Group, 1999).

Stress (timepoints- baseline, 4 weeks, 8 weeks): The Perceived Stress Scale-10 (PSS-

10), a widely used psychometrically sound instrument, was used to measure the degree to which

a participant perceived stress in her life during the past month, with items ranked on a 5-point

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Yoga for Women with Depression 11 Likert scale (S. Cohen & Williamson, 1988; S. Cohen, 1994; S. Cohen, Tyrrell, & Smith, 1993;

Hewitt, Flett, & Mosher, 1992; Logsdon & Hutti, 2006). Designed to measure stress from

chronic conditions or situations, the PSS-10 asks respondents to report about feelings such as

unpredictability, uncontrollability, and overloading of stress in their lives with items ranked on a

5-point Likert scale; scores range from 0-40 with the higher score corresponding to a higher

perceived stress level (S. Cohen, 1994).

Anxiety (timepoints- baseline, 4 weeks, 8 weeks): Current levels of anxiety (“state

anxiety”) were evaluated with the State-Trait Anxiety Inventory, Form Y (STAI). The S-Anxiety

portion of the STAI evaluates subjective state anxiety, measuring how an individual feels “right

now, at this moment” on a 4-point Likert scale. The 10-minute self-administered STAI has good

psychometric properties and is well-established in terms of feasibility and readability

(Spielberger, Gorsuch, & Lushene, 1970; Spielberger, 1983; Tilton, 2008).

Rumination (timepoints- baseline, 4 weeks, 8 weeks): Rumination, or repetitive

negative thinking, was evaluated with the 10-item Ruminative Responses Scale (RRS) which

was designed to evaluate the propensity to ruminate in association with sadness or depression. A

psychometrically sound and commonly used instrument, the RSS asks respondents to rate how

often they experience various aspects of rumination on a 4-point Likert scale (1=almost never to

4=almost always) (Treynor et al., 2003). The RRS has two factors of brooding (self-critical

pondering, as in “Why can’t I handle things better?”) and reflecting (emotionally-neutral

pondering or brainstorming, as in “Analyze your personality to try to understand why you are

depressed”). Some researchers separate the RRS into separate brooding and reflection subscales

because, in studies of adolescents and suicidal patients, high scores on the reflection items were

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Yoga for Women with Depression 12 associated with enhanced cognitive coping whereas high scores on brooding items were

associated with maladaptive coping (Burwell & Shirk, 2007; Crane, Barnhofer, & Williams,

2007). However, statistical data analysis for this study did not support separating the scales.

Interpersonal sensitivity and hostility (timepoints- baseline, 4 weeks, 8 weeks):

Subscales of the Brief Symptom Inventory were used to evaluate interpersonal factors often

involved in depression: interpersonal sensitivity and hostility. This feasible and valid tool was

designed to measure concerns about rejection by others and the tendency to be irritable during

interpersonal interactions. In the 9-item subscales for sensitivity and hostility, respondents are

asked to indicate how much certain concerns have distressed or bothered them during the past

month on a 5-point Likert scale (0=not at all, 4=extremely); examples of items include: “Your

feelings being easily hurt” (interpersonal sensitivity) and “Feeling easily annoyed or irritated”

(interpersonal hostility) (Derogatis & Melisaratos, 1983).

Statistical Analysis Plan

In order to best understand participants’ view of feasibility and acceptability of the

intervention, qualitative data were analyzed using a descriptive qualitative methodology with

phenomenological overtones (Sandelowski, 2000). The data collected were analyzed in the

manner of a hermeneutic circle (Agar, 1986; Cohen, Kahn, & Steeves, 2000). Data from

interviews with participants who completed the study or dropped out of the study were analyzed

for common themes regarding feasibility, acceptability, and effects of the yoga intervention or

attention-control activity.

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Yoga for Women with Depression 13

The quantitative data were analyzed using SPSS Version 19. Calculations of descriptive

statistics on demographic and study variables were completed in the form of means and standard

deviations (continuous variables) or frequencies and percentages (categorical variables). Baseline

group differences in demographic and baseline study variables were analyzed using independent

t-tests for continuous variables and chi-square tests for categorical variables; assumptions of

univariate normality and homogeneity of variance were met, using Fisher’s test of skewness and

Levene’s test. To determine if there were differences over time by group, separate multilevel

models were used to estimate differences in the slopes between the groups for the measures of

depression, stress, anxiety, rumination, and interpersonal sensitivity/hostility. Model parameters

have been estimated by restricted maximum likelihood, and the within-subject variance-

covariance matrix is modeled in the form determined by Akaike’s AIC criterion. Random

intercepts and slopes have been estimated from the data. At Level 1 (within-subject analysis), the

models estimated change for participants. At Level 2 (between-subjects analysis), the differences

in average slopes for each group (yoga group vs. the attention-control group) were modeled.

Testing revealed no major violations of assumptions (univariate normality, multivariate

normality and linearity), other than small sample size. AIC was used to determine the appropriate

model and covariance structure, and the random intercept and slope model and unstructured

covariance structure were the best fit for all models. Covariates were centered to the mean.

Given that this is a feasibility pilot study, an alpha = 0.05 has been used for all tests; trends are

closely examined.

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Yoga for Women with Depression 14

Results

Recruitment

A flowchart of participant recruitment, enrollment, and completion of the study is shown

in Figure 1. The 4-month recruitment period occurred from May to August 2011. A total of 48

women expressed interest in the study. Of these, 7 individuals did not complete the full

telephone screening to determine eligibility, either because they could not be reached or they

called after enrollment had ended. Five individuals who were eligible from the telephone

screening did not show up for their in-person screening/consent visits and were lost to follow-up;

their mean depression scores were 19.8 (SD = 5.6; range 10-24). Of those who did complete the

telephone screenings, 7 individuals were ineligible to participate because they did not have

sufficiently severe depression. Two other individuals were eligible based upon the telephone

screening criteria but were unable to participate in the full study because of schedule conflicts;

their mean depression scores were 16 (SD = 1.4). Twenty-seven individuals completed the in-

person screening, were enrolled as participants in the study, and were randomized to the yoga

group or the attention-control group. Nine individuals dropped out at some point during the study

(n = 6 from attention-control group; n = 3 from yoga group). The majority of those who dropped

out participated only in the screening visit and never participated in any aspect of the

intervention (n = 5 in attention-control group; n = 2 in yoga group); the rest dropped out in the

first few weeks of the intervention period (n = 1 in control group; n = 1 in yoga group). Most of

the participants from both groups agreed to be interviewed (n = 6 in attention-control group; n =

14 in yoga group), but some were lost to follow-up before exit interview (n = 6 in attention-

control group; n = 1 in yoga group).

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Yoga for Women with Depression 15 Sample

Twenty-seven participants enrolled in the study. See Table 2 for group differences on the

demographic characteristics of the study population, based upon independent t-tests for

continuous variables and chi-square tests for categorical variables. There were no significant

differences between the groups in most of the demographic variables such as age, ethnicity/race,

marital status, employment status, current major depressive episode, reported recent major life

changes, antidepressant/ anxiolytic use, current use of individual psychotherapy, and current

participation in exercise. As demonstrated in Table 3, there were no group differences in baseline

levels of the variables of interest (depression, anxiety, stress, ruminations, interpersonal

sensitivity and hostility), based upon independent t-tests for these normally distributed

continuous variables.

Retention and Adherence

Eighteen out of the original 27 participants completed the study. Retention rates differed

between the two groups, such that more participants in the yoga group (n = 12; 80%) completed

the study than did those in the attention-control group (n = 6; 50%). All participants attended an

average of 6.9±1.2 classes, with no significant difference between the groups in adherence to the

intervention (p = .18). The recommended “dose” of the yoga intervention was a once-weekly 75-

minute group class and approximately 20 minutes per day on other days (total of 195 minutes per

week or 1560 minutes over 8 weeks). The mean total minutes of yoga practiced by all

individuals in this group (1153.8±609.4 minutes) was less than the total recommended minutes;

however, as can be seen in the standard deviation, there was a wide range in the amount of home

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Yoga for Women with Depression 16 practice across individuals. On any given week, 40-50% of participants met the recommended

dosage of minutes in home yoga practice.

Completion Status

There were no statistically significant baseline differences between those who went on to

complete the intervention (n = 18) and those who did not (n = 9). Similar to those who completed

the study, most individuals who did not complete the study were white, single, had at least a

college degree, were taking an antidepressant, were participating in individual psychotherapy,

and were not exercising on a regular basis. The only trend towards significance that was

identified was in the area of reported recent major life changes at baseline. More completers (n =

12; 66.67%) than non-completers (n = 3; 33.33%) reported recent major life changes (χ2=2.7;

p=.051). There was no difference in baseline study variables between those who completed the

study and those who did not, such that the non-completers looked very similar to the completers

with regards to levels of depression, stress, anxiety, ruminations, and interpersonal factors.

Group Differences in Study Outcomes

In the first model represented in Table 4, we examined the longitudinal change by group

in depression (PHQ-9) using 5 time points (baseline, 2, 4, 6, and 8 weeks). The addition of

baseline stress significantly improved the model fit; thus, we will focus on this model. The

baseline average depression score for those in the usual care group was 17.5 for a participant

with average levels of stress at baseline (see intercept coefficient), indicating moderately severe

depression (a score between 15-20 on the PHQ-9). The significant covariate of baseline stress

indicated that as baseline stress increased, the baseline depression score also increased. All

participants, as a whole, had decreasing levels of depression over time (indicated by the

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Yoga for Women with Depression 17 significant time coefficient). There were no significant differences in depression scores over time

between the yoga and control groups (non-signficant group by time interaction).

In the second model represented in Table 4, we evaluated whether or not there were

group differences in ruminations over time at 3 time points (baseline, 4, and 8 weeks). The

addition of baseline depression did not improve the model fit so this variable was not used as a

covariate. Baseline stress was a significant covariate that did improve model fit, thus it will be

included in the model for rumination. The baseline average rumination score was 25.9 for a

participant in the control group. As baseline stress levels increased, baseline rumination scores

also increased (indicated by a significant baseline stress coefficient). The trend in group

differences over time (p = .083) indicated that the yoga group had reduced rumination scores

over time compared to the control group (see Figure 2). The coefficient of time was not

significant, suggesting that there was not an equivalent decrease in rumination scores in the

control group.

Longitudinal changes in other study variables, including anxiety, stress, and interpersonal

sensitivity/ hostility, were examined with additional models not represented in the table. Results

of these models revealed a significant time effect such that there was a decrease in scores in all

measures in all participants over time. However, there were no differences in anxiety, stress, and

interpersonal/hostility between the yoga and attention-control groups over time. In addition, the

dose of yoga (total minutes of yoga practiced during the study) was evaluated, but was not a

significant covariate in any model.

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Yoga for Women with Depression 18 Feasibility and Acceptability: Qualitative Findings

Three main themes regarding feasibility and acceptability arose from the data from the

semi-structured exit interviews with study participants and their daily logs. Quotes from

participants are presented to support and illustrate these themes. Participants also provided

general suggestions for future yoga research for depression.

Theme 1- Feasibility: Barriers to participation. The first theme reflects how

scheduling difficulties related to work and life responsibilities were the main barriers to

participation in and completion of the study. Of the study participants who dropped out of the

study, all of them cited work and home-life responsibilities as barriers to their participation in the

study. They echoed one woman’s statement about the busy nature of her life, when she stated “I

am a grad student, I’ve got a pretty demanding job, and then there are other life demands … it’s

just hard to do everything.” Many completers of the yoga intervention suggested that their busy,

fast-paced lifestyle became a vicious cycle of contributing to stress and depression while also

preventing them from participating in self-care. One participant stated that, due to her busy life,

she “just didn’t have anything in me to do much of anything” on the days she was to do the home

practices. However, for some women, coming to terms with their limitations was an essential

part of the process of stopping the negative self-judgments typical in depression, as described by

one participant: “At first, I was feeling bad that I couldn’t do the whole practice all the time…

[but I learned that] it’s not about how much you didn’t do, it’s about how it helped you today… I

really took that to heart.”

Theme 2- Acceptability of yoga and health-education: Decreased depression. The

second theme reflects how participants in both the yoga and attention-control group reported an

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Yoga for Women with Depression 19 improved mood during their time in the study, which supported acceptability of the intervention

and control activity. In the exit interviews, participants in both the health-education (attention-

control) and the yoga groups consistently reported a sense of decreased depression over the

course of the study. However, the reasons cited for this perceived decrease in depression were

different between the two groups. Those in the attention-control group stated they had decreased

depression because they felt increased motivation to care for themselves combined with active

social support. Participants in the attention-control group consistently suggested that they felt

less depressed because they had started to care for themselves and that they benefitted from

talking with others in the attention-control group. One participant suggested that “signing up for

the study refocused my need to take care of myself,” signifying the association between self-care

and decreased depression. In contrast, those in the yoga group felt yoga helped their mood

because it provided a coping strategy to deal with persistent negative thoughts about stress in

their lives while also increasing a sense of connectedness to themselves and to others around

them. For example, one participant commented that learning how to be mindful of the breath

and body through yoga helped her break patterns of self-judging thoughts: “I normally look at all

the things I didn’t get done or do perfectly … but in the class I learned to focus and be pleased

with just doing a little something for me.” Participants repeatedly commented that they learned

through yoga to manage their thoughts, by “de-stressing” and letting “thoughts go by without

obsessing.” Another participant suggested that she was “more alert” to herself, thus enhancing

her personal confidence with life in general. Many participants suggested that yoga was

empowering; this is elucidated in one participant’s statement that, after a few weeks of yoga

practice, she had a general “feeling of being more capable” of doing yoga and other activities of

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Yoga for Women with Depression 20 daily life. Participants in the yoga group suggested that they also felt decreased depression

because they gained a profound sense of “connectedness” with others in their classes. One

participant expressed her feelings about the benefit of a social interaction through yoga that

transcended conversation: “shared consciousness was there, when everyone was together. The

shared centeredness is very powerful, it makes you feel a feeling of connectedness with

everything …even by just breathing together.”

Theme 3- Feasibility and acceptability of yoga: Motivators for practice. The third

theme reflects how various motivators affected the feasibility and acceptability of the yoga

intervention. When questioned about their experiences with home practice in the yoga

intervention and the likelihood of continuing with their yoga practice, all of the participants

discussed the topic of motivation in various forms. The DVD, class handouts, and daily logs

were described as partial motivators. The gained experience of an improved mood and enhanced

self-confidence were also described as motivators and key factors, particularly when participants

considered how to incorporate yoga into their lives after the end of the study.

As tools to facilitate home yoga practice, the DVD and weekly yoga class handouts were

motivators for some, but not all. When asked about the value of these tools, participants had

mixed reviews. A few loved the DVD and felt that it was very motivating for home practice

during the study and could be helpful in the future. One participant reported: “Both class and

DVD gave me something different… it’s wonderful to see a woman who is just a normal looking

woman who is doing yoga. That was very encouraging to me.” Some participants used certain

sections of the DVD that they found appealing, typically the warm-up, breathing, and meditation

chapters. The majority of participants, however, preferred to use only the handouts of poses from

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Yoga for Women with Depression 21 class each week, stating that they had gained confidence with the routine that they had learned in

the safety of their group class. One participant said “I stuck to the comfort zone of the exercises

that I learned in class” and another suggested that “I felt like what I learned during the weekly

class was the best to think about.”

With regards to the feasibility of the home yoga aspect of the intervention, many

commented that the daily log acted as a motivator to help them adhere to the recommended

practice. One participant stated: “Sometimes I didn’t want to get out of bed … but I would get

out of bed and breathe and stretch because I knew I had to fill out that log!” Another suggested

that the home practice and daily logs helped “add structure to [her] days.” This log occasionally

triggered a sense of guilt in some participants who felt they had not completed their

“homework.” Nonetheless, many participants stated that they appreciated the sense of

responsibility that came with having a log to fill out. One participant succinctly summarized this

feeling with the following statement: “[I needed] that push and that accountability to do it; that

sheet of paper was there and I said ‘okay, I need to write something down.’”

When directly asked by the investigator about the most important motivation for sticking

with yoga practice, the most common answer was that participants felt better after yoga practice

thus reinforcing their motivation to continue with the protocol. One participant said that she

would stick with her home yoga practice because she “would feel better afterwards, and that

encouragement helped.” Another participant echoed this sentiment with the following comment:

“Now, since I’m kind of on a roll and gotten used to doing it every day or almost every day,

when I don’t do it, I feel it in my body and my emotions. That’s kind of motivation itself.”

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Yoga for Women with Depression 22

Participants’ suggestions for feasibility of future studies. When asked by the

investigator about what they liked the least in the study and for suggestions for designing future

research studies, a few participants had ideas to share. First, one participant wished for a longer

time-frame of the study, beyond 8 weeks, saying:

When you’re doing something consistently for a long time, it sinks in more. The first two

to three weeks you’re honestly not there yet, you don’t grasp it yet. But by then, it’s like

you’re at mid-way point and you’re almost done and [the routine is] not really set in

stone.

Second, some participants wished for less “homework” and more frequent group classes. Despite

a general dislike of having to write in a log, participants consistently stated that future research

studies should continue to include the combination of group classes and home practice. One

participant reflected positively about this combination, saying “it wasn’t just ‘here’s a class’ or

just ‘here’s a DVD,’ but the combination of the two. I was really glad that all of that was

incorporated in [the study].” Fourth and finally, a number of participants suggested that a “buddy

system” or “accountability partners,” in the form of participant-to-participant communication

outside of class, could have been helpful for encouraging adherence to home practice during the

study as well as after the study was completed.

Discussion

This study provides support for the feasibility and acceptability of yoga as a

complementary therapy for women with depression, as evidenced through examination of

recruitment, retention, adherence, and the results of the quantitative and qualitative data. In

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Yoga for Women with Depression 23 addition, the findings suggest that, despite the fact that the yoga group and attention-control

group had the same degree of decreased depression over time, yoga appears to be uniquely

helpful for decreasing ruminations.

Recruitment, Retention, Acceptability, and Feasibility

Ease of recruitment for the study itself is an important indicator of acceptability of yoga

by women with depression. Despite our initial concerns that the common depressive symptom of

anhedonia would be a barrier to women volunteering for a study, we were able to garner the

interest of many women with MDD and moderate to severe depressive symptoms in a 4-month

time span. Referrals from psychotherapists and psychiatrists were an important aspect of the

recruitment process. In addition, we were able to recruit a racially and ethnically diverse group

of participants that mirrored the demographics of the recruitment area. The most effective

recruitment strategies were the use of word-of-mouth and placement of brochures at healthcare

provider offices. There were only two women who declined to participate in the study after the

initial telephone screening, citing schedule issues. However, there were four additional women

who were “no shows” to the next screening and consent visit. These women had slightly higher

depression scores than those who initially declined the study. Future research is warranted to

determine whether “no shows” are too depressed and anhedonic to meet the investigator for the

consent visit or whether there are other factors involved.

The retention rate of the yoga group was much higher than that of the control group.

Unfortunately, it is difficult to compare reasons for the differing retention rates because many of

the dropouts in the control group were lost to follow-up. The only dropout from the control

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Yoga for Women with Depression 24 group who participated in an interview suggested that she could not continue due to schedule

conflicts, which is consistent with the reasons in the yoga group. Attrition is often high in control

groups, but the attention-control group was designed based upon the literature supporting health

education sessions as reasonable for retention (Davis, Broome, & Cox, 2002; Gross et al., 2010;

Innes, 2009; Lengacher et al., 2001; Mather et al., 2002; Trivedi et al., 2006; Williams et al.,

2010). In an attempt to gain insight into potential mediators for this attrition, we evaluated

baseline information about the dropouts. Interestingly, more study completers reported recent

major stressful life changes at baseline than did those who dropped out of the study; this is the

opposite scenario of what we would have expected, given that stressful life events are often

associated with worsened depression and increased anhedonia (Kendler, Thornton, & Gardner,

2000). Future research with a larger sample size is warranted for evaluating differences in and

the impact of retention rates. Strategies for improving retention rates, such as those that enhance

how women cope with scheduling difficulties, should be evaluated in future studies.

The qualitative findings support the acceptability of the yoga intervention for depression.

All of the women who participated in the yoga group reported that they enjoyed participating in

the yoga classes and they felt that yoga was effective for decreasing their depression and

associated symptoms. As the study progressed, participants gained the felt experience of the

benefits of yoga that served as an important internal motivator for their continued participation.

During the interviews and in their logs, participants reflected on an increased awareness of the

enjoyable outcomes of yoga, such as feelings of physical and mental wellness (Vealey, 2007).

Research suggests that personal positive experiences contribute to self-efficacy, whereby

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Yoga for Women with Depression 25 participants feel more motivated for and capable of participating in a yoga routine, thereby

reinforcing future practice (Whaley, 2004).

In terms of the feasibility of the home practice aspect of the yoga intervention, daily life

stresses, in the form of family, work and/or school responsibilities, were a barrier to adherence to

the full recommended dose of yoga. This is consistent with the literature that suggests that these

responsibilities often strain depressed women’s abilities to prioritize self-care activities such as

yoga and may affect well-being (Cotter & Lachman, 2010; Keita, 2007; Nolen-Hoeksema,

2006). Although several participants felt that it was difficult to find time for themselves to

practice yoga at home, many reported that they learned to have realistic goals and expectations of

themselves for their yoga practice; these realistic goals seemed to translate into a realistic view

of their ability to deal with the world around them, which may be beneficial for their long-term

engagement in self-care (Son, Kerstetter, Mowen, & Payne, 2009). Any psychosocial

intervention requires time and effort on the part of the individual, which may continue to be a

challenge in the use of yoga for depression. Nonetheless, the dose of home yoga practice

received by participants in this study was not a significant covariate in our data analysis. In other

words, individuals with more time in home practice did not necessarily have a greater decrease in

depression or ruminations. This finding is interesting, particularly because it is unknown what

the minimum effective “dose” of yoga may be and whether it includes home practice versus

group classes (Uebelacker et al., 2010). Participants in our study consistently stated that they felt

the most noteworthy benefit from the group classes and experienced more barriers to home

practice, so future researchers may wish to study these factors more fully in a long-term study. In

addition, as suggested by multiple participants, future researchers may wish to evaluate the role

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Yoga for Women with Depression 26 of a “buddy system” for long-term adherence, which is a social approach for relapse prevention

(Lox, Martin, & Petruzzello, 2006).

The findings from the qualitative data supported the use of behavioral strategies to

facilitate adherence to the home yoga practice (i.e., the class handouts, the DVD, daily logs). The

majority of the yoga group participants reported using class handouts rather than the DVD to

guide their home practice, citing an enhanced sense of confidence about and competence with

yoga. It is not surprising that participants tended to choose a home practice that mirrored their

group class practice because a sense of confidence and competence has been shown to help

individuals maintain consistency with an intervention, particularly when combined with a

positive social environment and the reinforcement with positive affective states (Whaley, 2004).

The participants also cited the daily yoga logs as a motivator for regular practice during the study

itself. The use of logs may have contributed to the foundational skill of self-awareness. This tool

for gaining awareness of thoughts and feelings about mood and participation in an intervention

has been shown to enhance self-regulation and adherence to interventions (Vealey, 2007).

Although participants did not always fully complete the logs and many participants expressed

frustration with keeping up with them, the logs may have been a relevant self-monitoring

strategy. The literature suggests that, even if a log is incomplete, it can be helpful for providing

an avenue for self-evaluation and for reinforcing consistency with the intervention (Lox et al.,

2006). By writing in the column in the log about her mood, the participant may have been able to

see clearly whether or not participating in yoga was beneficial. Considering this, future

researchers may wish to continue to use logs, or a similar method, to help participants adhere to

an intervention.

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Yoga for Women with Depression 27 Unique Effect of Yoga: Trend in Decreased Rumination

The study supports the need for continued large-scale research studies to evaluate the

effects of yoga on depression as compared to an active control group. Participants in both groups

had a significant decrease in depression scores over time, such that the mean depression score

decreased from a “moderately severe” level to a “minimal” level of depression in 8 weeks.

Although the attention-control group had a similar decrease in depression over time, the yoga

group had a unique trend towards decreased ruminations, when controlling for baseline stress. At

each time point during the study, the yoga group had a greater reduction in rumination scores

compared to the control, as seen in Figure 2. This suggests that, perhaps given more time in the

intervention, the yoga group may have ultimately had a more significantly decreased rumination

score. Data from the qualitative interviews support this, as many participants verbalized a desire

for the intervention to be a bit longer to help them fully establish yoga in their routine and feel

more confident with their yoga abilities.

The quantitative and qualitative findings suggest that there may be a few reasons that

account for decreased depression in the attention-control group without a decrease in

ruminations. The yoga and the attention-control groups shared a few similar aspects, in that they

both required women to voluntarily engage in an activity requiring participants to get out of the

house, that involved social support, and that encouraged self-care. These factors may have been

important enough to enact change in all participants’ perception of depression but not necessarily

ruminations in the attention-control group. First, volunteer bias may have played an important

role in decreasing depression because, as many participants in the attention-control group

reported, simply volunteering for a research study was a motivator for self-care. Second, the

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Yoga for Women with Depression 28 simple act of bringing women with depression together may be an intervention in itself. Studies

suggest that the social environment plays a key role in mental health (Curley, Jensen, Mashoodh,

& Champagne, 2011; Luyten, Blatt, Van Houdenhove, & Corveleyn, 2006). Indeed, many of the

women in the attention-control group reported that they benefitted from talking with others in the

group and hearing about others’ experiences, conceivably similar to the value of therapeutic

group modalities (Cuijpers et al., 2010). This may be a key difference between the groups,

however, because the participants in the yoga group often discussed how connectedness occurred

transcendent of dialogue. In fact, connectedness, or a general sense of self in the world, has been

shown to be a more powerful and enduring mediator for decreasing depression than direct social

support (Deary, Roche, Plotkin, & Zahourek, 2011; Segrin & Rynes, 2009; Uebelacker, Tremont

et al., 2010; Williams & Renee, 2006). Future researchers may wish to include measures of

social connectedness to more closely evaluate this potential difference. Third, two women in the

attention-control group encouraged each other to join a gym; physical activity has been shown to

significantly improve the mood, so this simple change in lifestyle in two out of the six women in

the attention-control group may be partly responsible for the change in depression level (Mead et

al., 2009). We can only speculate about the impact of these factors on our results; to increase

power to detect changes between groups, future large-scale studies should evaluate these factors

with a larger sample size.

Study Limitations

Generalizability of this study is limited for a number of reasons. First, the nature of a

pilot study is a small sample size, which places limits upon quantitative methodologies and

generalizability. Second, as with any study that requires volunteer participation, volunteer bias

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Yoga for Women with Depression 29 may have occurred due to convenience sampling, such that the sample may include those who

already intended to enact changes for self-care and mental wellness. Third, attrition rates were

relatively high in the attention-control group as compared to the yoga group, despite multiple

strategies to retain participants such as weekly telephone calls to address barriers to participation.

We were unable to include dropouts in the quantitative analysis because most dropped out before

receiving any of the intervention and completing any study instruments beyond baseline. Finally,

beyond the exit interview, we did not engage in long-term follow-up of participants, which may

have provided additional information about the feasibility and acceptability of long-term yoga

practice for women with depression. Previous studies have found multiple barriers to long-term

continuation of yoga (Alexander, Taylor, Innes, Kulbok, & Selfe, 2008; Atkinson & Permuth-

Levine, 2009). A longer study with depressed women would be beneficial for evaluating what

strategies for maintenance of yoga practice are most helpful and whether the positive benefits of

yoga practice are sustained over time.

Conclusion

The results of this study suggest that yoga is acceptable to and feasible for this

population. Despite the small sample size, there was a trend towards decreased ruminations in

the yoga group only, which may provide insight into one possible mechanism for yoga’s effect

on depression. Further research is warranted to evaluate if, given enough time and with a larger

sample size, the effect of the decreased ruminations could cause a more significant decrease in

depression in the yoga group. Qualitative findings provide support for the feasibility,

acceptability, and benefits of the use of yoga with depressed women. This pilot study was

designed carefully to address multiple methodological limitations of previous studies of yoga for

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Yoga for Women with Depression 30 depression and supports the need for replication in future large-scale research into yoga as a

complementary therapy for women with depression.

References

Agar, M. (1986). Speaking of ethnography. Thousand Oaks, CA: Sage Publications, Inc.

Alexander, G. K., Taylor, A. G., Innes, K. E., Kulbok, P., & Selfe, T. K. (2008). Contextualizing

the effects of yoga therapy on diabetes management: A review of the social determinants of

physical activity. Family & Community Health, 31(3), 228-239.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental

disorders: Fourth edition, text revision (DSM-IV-TR) (4th ed.). Arlington, VA: American

Psychiatric Association.

Atkinson, N. L., & Permuth-Levine, R. (2009). Benefits, barriers, and cues to action of yoga

practice: A focus group approach. American Journal of Health Behavior, 33(1), 3-14.

Barnes, P. M., Bloom, B., & Nahin, R. L. (2009). Complementary and alternative medicine use

among adults and children: United states, 2007. National Health Statistics Reports, (12), 1-

23.

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Yoga for Women with Depression 31 Beal, C. C., Stuifbergen, A., Volker, D., & Becker, H. (2009). Women's experiences as members

of attention control and experimental intervention groups in a randomized controlled trial.

Canadian Journal of Nursing Research, 41(4), 16-31.

Bennett, S., Weintraub, A., & Khalsa, S. (2008). Initial evaluation of the LifeForce yoga

program as a therapeutic intervention for depression. International Journal of Yoga

Therapy, 28, 49-57.

Benson, H. (1975). The relaxation response. New York: Avon Books.

Birdee, G. S., Legedza, A. T., Saper, R. B., Bertisch, S. M., Eisenberg, D. M., & Phillips, R. S.

(2008). Characteristics of yoga users: Results of a national survey. Journal of General

Internal Medicine, 23(10), 1653-1658.

Branchi, I., Schmidt, M. (2011). In search of the biological basis of mood disorders: Exploring

out of the mainstream. Psychoneuroendocrinology, 36(3), 305-307.

Broota, A., & Dhir, R. (1990). Efficacy of two relaxation techniques in depression. India: Journal

of Personality and Clinical Studies.

Brown, R. P., & Gerbarg, P. L. (2005a). Sudarshan kriya yogic breathing in the treatment of

stress, anxiety, and depression. part II--clinical applications and guidelines. Journal of

Alternative & Complementary Medicine, 11(4), 711-717.

Brown, R. P., & Gerbarg, P. L. (2005b). Sudarshan kriya yogic breathing in the treatment of

stress, anxiety, and depression: Part I-neurophysiologic model.[erratum appears in J altern

ACC

EPTE

D M

ANU

SCR

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ACCEPTED MANUSCRIPT

Yoga for Women with Depression 32

complement med. 2005 apr;11(2):383-4]. Journal of Alternative & Complementary

Medicine, 11(1), 189-201.

Brown, R. P., & Gerbarg, P. L. (2009). Yoga breathing, meditation, and longevity. Annals of the

New York Academy of Sciences, 1172, 54-62.

Burwell, R. A., & Shirk, S. R. (2007). Subtypes of rumination in adolescence: Associations

between brooding, reflection, depressive symptoms, and coping. Journal of Clinical Child

and Adolescent Psychology : The Official Journal for the Society of Clinical Child and

Adolescent Psychology, American Psychological Association, Division 53, 36(1), 56-65.

Butler, L. D., Waelde, L. C., Hastings, T. A., Chen, X. H., Symons, B., Marshall, J., . . . Spiegel,

D. (2008). Meditation with yoga, group therapy with hypnosis, and psychoeducation for

long-term depressed mood: A randomized pilot trial. Journal of Clinical Psychology, 64(7),

806-820.

Cohen, M., Kahn, D., & Steeves, R. (2000). Hermeneutic phenomenological research: A

practical guide for nurse researchers. Thousand Oaks, CA: Sage Publications, Inc.

Cohen, S. (1994). Perceived stress scale. Retrieved February 2, 2010, from

www.mindgarden.com/docs/PerceivedStressScale.pdf

Cohen, S., & Williamson, G. (1988). Perceived stress in a probability sample of the united states.

In S. Oskamp, & S. Spacapan (Eds.), The social psychology of health. (pp. 31-67).

Thousand Oaks, CA: Sage Publications, Inc.

ACC

EPTE

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ANU

SCR

IPT

ACCEPTED MANUSCRIPT

Yoga for Women with Depression 33 Cohen, S., Tyrrell, D. A., & Smith, A. P. (1993). Negative life events, perceived stress, negative

affect, and susceptibility to the common cold. Journal of Personality and Social

Psychology, 64(1), 131-140.

Conway, M., Csank, P. A. R., Holm, S. L., & Blake, C. K. (2000). On assessing individual

differences in rumination on sadness. Journal of Personality Assessment, 75(3), 404-425.

Cotter, K. A., & Lachman, M. E. (2010). No strain, no gain: Psychosocial predictors of physical

activity across the adult lifespan. Journal of Physical Activity and Health, (7), 584-594.

Crane, C., Barnhofer, T., & Williams, J. M. (2007). Reflection, brooding, and suicidality: A

preliminary study of different types of rumination in individuals with a history of major

depression. British Journal of Clinical Psychology, 46, 497-504.

Cuijpers, P., van Straten, A., Schuurmans, J., van Oppen, P., Hollon, S. D., & Andersson, G.

(2010). Psychotherapy for chronic major depression and dysthymia: A meta-analysis.

Clinical Psychology Review, 30(1), 51-62.

Curley, J. P., Jensen, C. L., Mashoodh, R., & Champagne, F. A. (2011). Social influences on

neurobiology and behavior: Epigenetic effects during development.

Psychoneuroendocrinology, 36(3), 352-371.

Davis, L., Broome, M., & Cox, R. (2002). Maximizing retention in community-based clinical

trials. Journal of Nursing Scholarship, 34(1), 47-53.

ACC

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SCR

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ACCEPTED MANUSCRIPT

Yoga for Women with Depression 34 Deary, L., Roche, J., Plotkin, K., & Zahourek, R. (2011). Intentionality and hatha yoga: An

exploration of the theory of intentionality, the matrix of healing- a growth model. Holistic

Nursing Practice, 25(5), 246-253.

Derogatis, L., & Melisaratos, N. (1983). The brief symptom inventory: An introductory report.

Psychological Medicine, 13, 595-605.

Desikachar, K., Bragdon, L., & Bossart, C. (2005). The yoga of healing: Exploring yoga's

holistic model for health and well-being. International Journal of Yoga Therapy, 15, 17-39.

Doyle, L., Brady, A., & Byrne, G. (2009). An overview of mixed-methods research. Journal of

Nursing Research, 14(2), 175-185.

Weintraub, A. (Producer), & Duncan, D. (Director). (2007). LifeForce yoga to beat the blues:

Level 1. [Video/DVD] Pennsauken, NJ: Disc Makers.

Gross, C. R., Kreitzer, M. J., Thomas, W., Reilly-Spong, M., Cramer-Bornemann, M., Nyman, J.

A., . . . Ibrahim, H. N. (2010). Mindfulness-based stress reduction for solid organ transplant

recipients: A randomized controlled trial. Alternative Therapies in Health & Medicine,

16(5), 30-38.

Halbreich, U., & Kahn, L. S. (2007). Atypical depression, somatic depression and anxious

depression in women: Are they gender-preferred phenotypes? Journal of Affective

Disorders, 102(1-3), 245-258.

ACC

EPTE

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SCR

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ACCEPTED MANUSCRIPT

Yoga for Women with Depression 35 Hauenstein, E. J. (1996). A nursing practice paradigm for depressed rural women: Theoretical

basis. Archives of Psychiatric Nursing, 10(5), 283-292.

Hewitt, P. L., Flett, G. L., & Mosher, S. W. (1992). The perceived stress scale: Factor structure

and relation to depression symptoms in a psychiatric sample. Journal of Psychopathology

and Behavioral Assessment, 14(3), 247-257.

Innes, K. E. (2009). Abstracts from the North American Research Conference on

Complementary and Integrative Medicine. May 12-15, 2009. Minneapolis, MN. Journal of

Alternative and Complementary Medicine (New York, N.Y.), 15(4), 446-458.

Janakiramaiah, N., Gangadhar, B. N., Naga Venkatesha Murthy, P. J., Harish, M. G.,

Subbakrishna, D. K., & Vedamurthachar, A. (2000). Antidepressant efficacy of sudarshan

kriya yoga (SKY) in melancholia: A randomized comparison with electroconvulsive therapy

(ECT) and imipramine. Journal of Affective Disorders, 57(1-3), 255-259.

Keita, G. P. (2007). Psychosocial and cultural contributions to depression in women:

Considerations for women midlife and beyond. Journal of Managed Care Pharmacy:

JMCP, 13(9), S12-S15.

Kendler, K. S., Thornton, L. M., & Gardner, C. O. (2000). Stressful life events and previous

episodes in the etiology of major depression in women: An evaluation of the "kindling"

hypothesis. The American Journal of Psychiatry, 157(8), 1243-1251.

ACC

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ACCEPTED MANUSCRIPT

Yoga for Women with Depression 36 Kessler, R., Berglund, P., Demler, O., Jin, R., Koretz, D., Merikangas, K., . . . Wang, P. (2003).

The epidemiology of major depressive disorder: Results from the National Comorbidity

Survey Replication (NCS-R). Journal of the American Medical Association, 289(3), 3095-

3105.

Kinser, P. A., Goehler, L. E., & Taylor, A. G. (2012). How might yoga help depression? A

neurobiological perspective. EXPLORE: The Journal of Science and Healing, 8(2), 118-

126.

Kirkwood, G., Rampes, H., Tuffrey, V., Richardson, J., & Pilkington, K. (2005). Yoga for

anxiety: A systematic review of the research evidence. British Journal of Sports Medicine,

39(12), 884-891.

Kroenke, K., Spitzer, L., & Williams, J. (2001). MOS short-form general health survey. Journal

of General Internal Medicine, 16, 606-613.

Lafrance, M. N., & Stoppard, J. M. (2006). Constructing a non-depressed self: Women's

accounts of recovery from depression. Feminism & Psychology, 16(3), 307-325. doi:

Lengacher, C. A., Gonzalez, L. L., Giuliano, R., Bennett, M. P., Cox, C. E., & Reintgen, D. S.

(2001). The process of clinical trials: A model for successful clinical trial participation.

Oncology Nursing Forum, 28, 1115-1120.

ACC

EPTE

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Yoga for Women with Depression 37 Lindquist, R., Wyman, J. F., Talley, K., Findorff, M. J., & Gross, C. R. (2007). Design of

control-group conditions in clinical trials of behavioral interventions. Journal of Nursing

Scholarship, 39(3), 214-221.

Logsdon, M. C., & Hutti, M. H. (2006). Readability: An important issue impacting healthcare for

women with postpartum depression. MCN: The American Journal of Maternal Child

Nursing, 31(6), 350-355.

Lopez, C. M., Driscoll, K. A., & Kistner, J. A. (2009). Sex differences and response styles:

Subtypes of rumination and associations with depressive symptoms. Journal of Clinical

Child and Adolescent Psychology : The Official Journal for the Society of Clinical Child

and Adolescent Psychology, American Psychological Association, Division 53, 38(1), 27-35.

Löwe, B., Kroenke, K., Herzog, W., & Gräfe, K. (2004). Measuring depression outcome with a

brief self-report instrument: Sensitivity to change of the patient health questionnaire (PHQ-

9). Journal of Affective Disorders, 81(1), 61-66.

Lox, C. L., Martin, K. A., & Petruzzello, S. J. (2006). Physical activity interventions. The

psychology of exercise: Integrating theory and practice (2nd ed., pp. 147-18). Scottsdale,

AZ: Holcomb Hathaway.

Luyten, P., Blatt, S. J., Van Houdenhove, B., & Corveleyn, J. (2006). Depression research and

treatment: Are we skating to where the puck is going to be? Clinical Psychology Review,

26(8), 985-999.

ACC

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Yoga for Women with Depression 38 Lyubomirsky, S., & Tkach, C. (2004).The consequences of dysphoric rumination. In C.

Papageorgiou, & A. Wells (Eds.), Depressive rumination: Nature, theory, and treatment ().

Chicester, England: John Wiley & Sons Ltd.

Marcus, S. M., Kerber, K. B., Rush, A. J., Wisniewski, S. R., Nierenberg, A., Balasubramani, G.

K., . . . Trivedi, M. H. (2008). Sex differences in depression symptoms in treatment-seeking

adults: Confirmatory analyses from the sequenced treatment alternatives to relieve

depression study. Comprehensive Psychiatry, 49(3), 238-246.

Mather, A., Rodriguez, C., Guthrie, M., McHarg, A., Reid, I., & McMurdo, M. (2002). Effects of

exercise on depressive symptoms in older adults with poorly responsive depressive disorder:

Randomised controlled trial. The British Journal of Psychiatry, 180(5), 411-415.

Mathew, S. J., & Charney, D. S. (2009). Publication bias and the efficacy of antidepressants.

American Journal of Psychiatry, 166(2), 140-145.

Mead, G., Morley, W., Campbell, P., Greig, C., McMurdo, M., & Lawlor, D. (2009). Exercise

for depression. Cochrane Database of Systematic Reviews, 3, CD004366.

Morrison, R., & O'Connor, R. (2008).A systematic review of the relationship between

rumination and suicidality. Suicide and Life-Threatening Behavior, 38, 523-538.

National Center for Complementary and Alternative Medicine (NCCAM). (2010). About yoga.

Retrieved 9/26, 2010, from http://nccam.nih.gov/health/yoga/

ACC

EPTE

D M

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SCR

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Yoga for Women with Depression 39 Nolen-Hoeksema, S. (2006). The etiology of gender differences in depression. In G. P. Keita

(Ed.), Understanding depression in women: Applying empirical research to practice and

policy. (pp. 9-43). Washington, DC US: American Psychological Association.

Nolen-Hoeksema, S., & Hilt, L. M. (2009). Gender differences in depression. In C. L. Hammen

(Ed.), Handbook of depression (2nd ed.). (pp. 386-404). New York, NY US: Guilford Press.

Nolen-Hoeksema, S., Wisco, B. E., & Lyubomirsky, S. (2008). Rethinking rumination.

Perspectives on Psychological Science, 3(5), 400-424.

Pigott, H., Leventhal, A., Alter, G., & Boren, J. (2010). Efficay and effectiveness of

antidepressants: Current status of research. Psychotherapy and Psychosomatics, 79, 267-

279.

Pilkington, K., Kirkwood, G., Rampes, H., & Richardson, J. (2005). Yoga for depression: The

research evidence. Journal of Affective Disorders, 89(1-3), 13-24.

Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing and

Health, 23, 334-340.

Segrin, C., & Rynes, K. N. (2009). The mediating role of positive relations with others in

associations between depressive symptoms, social skills, and perceived stress. Journal of

Research in Personality, 43(6), 962-971.

Sharma, V. K., Das, S., Mondal, S., Goswampi, U., & Gandhi, A. (2005). Effect of sahaj yoga on

depressive disorders. Indian Journal of Physiology & Pharmacology, 49(4), 462-468.

ACC

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Yoga for Women with Depression 40 Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., . . . Dunbar,

G. C. (1998). The mini-international neuropsychiatric interview (M.I.N.I.): The

development and validation of a structured diagnostic psychiatric interview for DSM-IV and

ICD-10. The Journal of Clinical Psychiatry, 59 Suppl 20, 22-33;quiz 34-57.

Smith, J. M., & Alloy, L. B. (2009). A roadmap to rumination: A review of the definition,

assessment, and conceptualization of this multifaceted construct. Clinical Psychology

Review, 29(2), 116-128.

Son, J., Kerstetter, D., Mowen, A., & Payne, L. (2009). Global self-regulation and outcome

expectations: Influences on constraint self-regulation and physical activity. Journal of Aging

and Physical Activity, 17, 307-326.

Sparrowe, L., & Walden, P. (2002). The woman's book of yoga and health: A lifelong guide to

wellness. Boston, MA.: Shambala.

Spielberger, C., Gorsuch, R., & Lushene, R. (1970). State-trait anxiety inventory. Palo Alto, CA:

Consulting Psychologists Press.

Spielberger, C. D. (1983). State-trait anxiety inventory (STAI.) Menlo Park, CA: Mind Garden.

Spitzer, R. L., Kroenke, K., Williams, J. B. W., & and the Patient Health Questionnaire Primary

Care Study Group,. (1999). Validation and utility of a self-report version of PRIME-MD:

The PHQ primary care study. JAMA: The Journal of the American Medical Association,

282(18), 1737-1744.

ACC

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Yoga for Women with Depression 41 Street, L. L., & Luoma, J. B. (2002). Control groups in psychosocial intervention research:

Ethical and methodological issues. Ethics & Behavior, 12(1), 1-30.

Taylor, A., Goehler, L., Galper, D., Innes, K., & Bourguignon, C. (2010). Top-down and bottom-

up mechanisms in mind-body medicine: Development of an integrative framework for

psychophysiological research. Explore, 6, 29-41.

Tilton, S. R. (2008). Review of the state-trait anxiety inventory (STAI). NewsNotes, 48(2), June

2, 2010.

Treynor, W., Gonzalez, R., & Nolen-Hoeksema, S. (2003). Rumination reconsidered: A

psychometric analysis. Cognitive Therapy and Research, 27(3), 247-259.

Trivedi, M. H., Greer, T. L., Grannemann, B. D., Church, T. S., Galper, D. I., Sunderajan, P., . . .

Carmody, T. J. (2006). TREAD: Treatment with exercise augmentation for depression:

Study rationale and design. Clinical Trials, 3(3), 291-305.

Turner, E. H., Matthews, A. M., Linardatos, E., Tell, R. A., & Rosenthal, R. (2008). Selective

publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med,

358(3), 252-260.

Uebelacker, L. A., Epstein-Lubow, G., Gaudiano, B. A., Tremont, G., Battle, C. L., & Miller, I.

W. (2010). Hatha yoga for depression: Critical review of the evidence for efficacy, plausible

mechanisms of action, and directions for future research. Journal of Psychiatric Practice,

16(1), 22-33.

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Yoga for Women with Depression 42 Uebelacker, L. A., Tremont, G., Epstein-Lubow, G., Gaudiano, B. A., Gillette, T., Kalibatseva,

Z., & Miller, I. W. (2010). Open trial of vinyasa yoga for persistently depressed individuals:

Evidence of feasibility and acceptability. Behavior Modification, 34(3), 247-264.

Vealey, R. S. (2007). Mental skills training in sport. In G. Tenenbaum, & R. C. Eklund (Eds.),

Handbook of sport psychology (3rd ed., pp. 287-309). Hoboken, NJ: John Wiley & Sons.

Weinstein, N., Brown, K. W., & Ryan, R. M. (2009). A multi-method examination of the effects

of mindfulness on stress attribution, coping, and emotional well-being. Journal of Research

in Personality, 43(3), 374-385.

Weintraub, A. (2004). Yoga for depression: A compassionate guide to relieve suffering through

yoga. New York, NY: Broadway Books.

Whaley, D. E. (2004). Seeing isn't always believing: Self-perceptions and physical activity

behaviors in adults. In M. R. Weiss (Ed.), Developmental sport and exercise psychology: A

lifespan perspective (pp. 289-311). Morgantown, WV: Fitness Information Technology.

Williams, K. L. G.,Renee V. (2006). Predicting depression and self-esteem from social

connectedness, support, and competence. Journal of Social & Clinical Psychology, 25(8),

855-874.

Williams, J. M., Russell, I. T., Crane, C., Russell, D., Whitaker, C. J., Duggan, D. S., . . .

Silverton, S. (2010). Staying well after depression: Trial design and protocol. BMC

Psychiatry, 10, 23-23.

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Table 1. Inclusion and Exclusion Criteria Inclusion criteria Exclusion criteria(1) adult women with a diagnosis of MDD or

dysthymia as confirmed by the M.I.N.I. Neuropsychiatric Interview (MINI) 6.0 depression module; and,

(2) moderate to severe depression, defined by a score of 10 or above on the 9-item Patient Health Questionnaire (PHQ-9)

(1) suicidality (MINI);(2) psychosis or mania (MINI); (3) physical conditions making yoga difficult (identified by the participant); (4) hospitalization or surgery in the past month; (5) changes in antidepressant medication dosing over the past month or expected changes during the intervention period; (6) regular yoga or meditation practice longer than one month within the past five years; and, (7) non-English speaking

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Table 2. Group Differences on Demographic Characteristics Group Assignment

Demographic Characteristics

Overall (n = 27)

mean (SD) or n (%)

Yoga (n = 15)

mean (SD) or n (%)

Attention-Control (n = 12)

mean (SD) or n (%)

Statistic p-

value

Age 43.26 (15.57) 40.93(15.84) 46.17 (15.40) -.86 Ŧ .40 Ethnicity/ Race White (non-Hispanic) Non-White

17 (62.96%) 10 (37.04%)

10 (66.67%) 5 (33.33%)

7 (58.33%) 5 (41.67%)

.19 ŧ

.66

Education <college degree ≥ college degree

10 (37.04%) 17 (62.96%)

3 (20.00%) 12 (80.00%)

7 (58.33%) 5 (41.67%)

4.20 ŧ

.04

Marital/Partner Status Single/ divorced Married/partnered

20 (74.1%) 6 (25.9%)

11 (73.3%) 4 (26.7%)

9 (75.00%) 3 (25.00%)

.01 ŧ

.92

Employment Status Full-time Part-time/ not working

13 (48.15%) 14 (51.85%)

8 (53.33%) 7 (46.67%)

5 (41.67%) 7 (58.33%)

.36 ŧ

.55

Current Major Depression (MDD or MDE)

22 (81.50%)

11 (73.33%)

11 (91.67%)

1.49 ŧ

.22

Reports Recent Major Life Changes

15 (55.56%)

9 (60.00%)

6 (50.00%)

.27 ŧ

.60

Current Use of Anti-Depressant Medications

17 (62.96%)

9 (60.00%)

8 (66.67%)

.13 ŧ

.72

Current Use of Anxiolytic Medications

10 (37.04%)

6 (40.00%)

4 (33.33%)

.13 ŧ

.72

Currently in Individual Psychotherapy

19 (70.37%)

11 (73.33%)

8 (66.67%)

.14 ŧ

.71

Currently Engages in Exercise (any type)

11 (40.74%)

7 (46.67%)

4 (33.33%)

.49 ŧ

.48

Ŧ = t-test ŧ = Chi-square  MDD = major depressive disorder; MDE = major depressive episode

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Table 3. Group Differences on Study Variables at Baseline

Group Assignment

Study Variable Overall (n= 27)

mean (SD)

Yoga (n=15)

mean (SD)

Attention-Control (n=12)

mean (SD)

t-test p-value

Depression (PHQ9)

15.44 (5.90) 14.67 (4.58) 16.42 (7.33) -.76 .46

Perceived Stress (PSS)

38.26 (5.66) 38.47 (4.58) 38.00 (6.95) .21 .84

Anxiety (STAI)

53.37 (12.81) 52.53 (13.51) 55.08 (12.32) -.51 .62

Ruminations (RSS)

26.30 (5.74) 27.40 (5.05) 24.92 (6.45) 1.12 .27

Interpersonal Sensitivity & Hostility

12.11 (7.24) 12.00 (4.91) 12.25 (9.65) -.08 .93

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Table 4. Differences over Time in Depression and Rumination- Multilevel Models Depression Rumination Models Unadjusted Adjusted Unadjusted Adjusted Intercept Time Group Group x time Baseline stress AIC df

17.3 -2.4* -3.1* -0.1 498.5 8

17.5* -3.3* -2.4* -0.1 0.5* 489.1 9

25.7* 1.2 -1.5 -2.0** 313.8 8

25.9* 1.0 -1.5 -2.0** 0.5* 310.9 9

* p<.05 **p<0.1 (trend) Adjusted models: baseline stress centered to the mean is covariate

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Figure 1. Participant Flow Diagram

Assessed for eligibility (N = 48)

Excluded (n = 21) Eligible, but declined participation

due to schedule conflicts (n = 2) Ineligible, not meeting inclusion

criteria (n = 7) Did not complete telephone screen

(n = 7) No-show to consent visit (n = 4)

Exit interview (qualitative) data analyzed (n = 14)

Quantitative data analyzed (n = 12) Excluded from analysis because did not

receive allocated intervention (n = 3)

Participated in exit interviews (n = 14)

Lost to follow-up (n = 1)

Allocated to yoga group (n = 15) Received allocated intervention (n = 12) Did not receive allocated intervention (n = 3) - dropped out before start of classes (n = 2) - dropped out in first week of class (n = 1)

Participated in exit interviews (n = 6) Lost to follow-up (n = 6)

Allocated to attention-control group (n = 12) Received allocated intervention (n = 6) Did not receive allocated intervention

(n = 6) - dropped out before start of classes (n = 5) - dropped out in 2nd week of classes (n = 1)

Exit interview (qualitative) data analyzed (n = 6)

Quantitative data analyzed (n = 6) Excluded from analysis because did not

receive allocated intervention (n = 6)

Allocation

Analysis

Follow-Up

Consented & Randomized (n = 27)

Enrollment

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Figure 2. Slopes of Rumination Scores Over Time by Group

fds